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Start ART in first 3 months in infants with perinatal HIV
MADRID – Infants with perinatal HIV infection are significantly more likely to achieve viral suppression by age 12 months if they start antiretroviral therapy (ART) before age 3 months than if physicians wait until 3-6 months of age, Paolo Palma, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.
He presented a study of the factors associated with time to virologic sup
The purpose of this study was to identify the key factors involved in attaining early virologic control of perinatally acquired HIV. This information is necessary to lay the groundwork for planned future investigations of immunotherapeutic strategies designed to achieve sustained ART-free remission. Such strategies are most likely to be successful in very young children who have not yet built up a massive viral load, explained Dr. Palma of Bambino Gesù Children’s Hospital in Rome.
“A major obstacle to curing HIV infection is persistence of virus as integrated proviral DNA in long-lived cells even after many years on ART. ART-free HIV remission is more likely to occur if viral suppression is achieved very early in infection,” he said.
The median age of the 420 subjects at the time ART was initiated was 2.9 months. Their CD4 cell percentage was 34%, with a median CD4 cell count of 1,780 and an average viral load at baseline of 316,228 copies/mL.
At 12 months of age, 84% of patients had achieved viral suppression. In multivariate analyses adjusted for initial ART regimen and geographic location, three factors were associated with this outcome: younger age at ART onset, a lower baseline viral load, and a higher per
Indeed, for each 1-month increase in age at onset of ART, the likelihood of virologic response at age 12 months decreased by 16%. Similarly, the rate of virologic response at 1 year of age decreased by 15% for each 10 copies/mL increase in viral load at the start of ART. In contrast, the likelihood of virologic suppression at age 12 months increased by 10% for each 10% increase in CD4 cell percentage at the start of treatment.
Among the variables that proved unrelated to virologic suppression at 1 year of age were gender, AIDS status, feeding style (breastfed versus bottle-fed), and ethnicity.
Dr. Palma reported having no relevant financial disclosures.
MADRID – Infants with perinatal HIV infection are significantly more likely to achieve viral suppression by age 12 months if they start antiretroviral therapy (ART) before age 3 months than if physicians wait until 3-6 months of age, Paolo Palma, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.
He presented a study of the factors associated with time to virologic sup
The purpose of this study was to identify the key factors involved in attaining early virologic control of perinatally acquired HIV. This information is necessary to lay the groundwork for planned future investigations of immunotherapeutic strategies designed to achieve sustained ART-free remission. Such strategies are most likely to be successful in very young children who have not yet built up a massive viral load, explained Dr. Palma of Bambino Gesù Children’s Hospital in Rome.
“A major obstacle to curing HIV infection is persistence of virus as integrated proviral DNA in long-lived cells even after many years on ART. ART-free HIV remission is more likely to occur if viral suppression is achieved very early in infection,” he said.
The median age of the 420 subjects at the time ART was initiated was 2.9 months. Their CD4 cell percentage was 34%, with a median CD4 cell count of 1,780 and an average viral load at baseline of 316,228 copies/mL.
At 12 months of age, 84% of patients had achieved viral suppression. In multivariate analyses adjusted for initial ART regimen and geographic location, three factors were associated with this outcome: younger age at ART onset, a lower baseline viral load, and a higher per
Indeed, for each 1-month increase in age at onset of ART, the likelihood of virologic response at age 12 months decreased by 16%. Similarly, the rate of virologic response at 1 year of age decreased by 15% for each 10 copies/mL increase in viral load at the start of ART. In contrast, the likelihood of virologic suppression at age 12 months increased by 10% for each 10% increase in CD4 cell percentage at the start of treatment.
Among the variables that proved unrelated to virologic suppression at 1 year of age were gender, AIDS status, feeding style (breastfed versus bottle-fed), and ethnicity.
Dr. Palma reported having no relevant financial disclosures.
MADRID – Infants with perinatal HIV infection are significantly more likely to achieve viral suppression by age 12 months if they start antiretroviral therapy (ART) before age 3 months than if physicians wait until 3-6 months of age, Paolo Palma, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.
He presented a study of the factors associated with time to virologic sup
The purpose of this study was to identify the key factors involved in attaining early virologic control of perinatally acquired HIV. This information is necessary to lay the groundwork for planned future investigations of immunotherapeutic strategies designed to achieve sustained ART-free remission. Such strategies are most likely to be successful in very young children who have not yet built up a massive viral load, explained Dr. Palma of Bambino Gesù Children’s Hospital in Rome.
“A major obstacle to curing HIV infection is persistence of virus as integrated proviral DNA in long-lived cells even after many years on ART. ART-free HIV remission is more likely to occur if viral suppression is achieved very early in infection,” he said.
The median age of the 420 subjects at the time ART was initiated was 2.9 months. Their CD4 cell percentage was 34%, with a median CD4 cell count of 1,780 and an average viral load at baseline of 316,228 copies/mL.
At 12 months of age, 84% of patients had achieved viral suppression. In multivariate analyses adjusted for initial ART regimen and geographic location, three factors were associated with this outcome: younger age at ART onset, a lower baseline viral load, and a higher per
Indeed, for each 1-month increase in age at onset of ART, the likelihood of virologic response at age 12 months decreased by 16%. Similarly, the rate of virologic response at 1 year of age decreased by 15% for each 10 copies/mL increase in viral load at the start of ART. In contrast, the likelihood of virologic suppression at age 12 months increased by 10% for each 10% increase in CD4 cell percentage at the start of treatment.
Among the variables that proved unrelated to virologic suppression at 1 year of age were gender, AIDS status, feeding style (breastfed versus bottle-fed), and ethnicity.
Dr. Palma reported having no relevant financial disclosures.
AT ESPID 2017
Key clinical point:
Major finding: With each 1-month delay in starting antiretroviral therapy, the likelihood of attaining viral suppression by age 12 months drops by 16%.
Data source: This observational study included 420 infants with perinatally acquired HIV infection who began antiretroviral therapy prior to age 6 months.
Disclosures: Dr. Palma reported having no relevant financial disclosures.
First EDition: ED Visits Increased in States That Expanded Medicaid, more
BY JEFF BAUER
There was a substantial increase in the number of ED visits in states that expanded Medicaid coverage in 2014, after the Affordable Care Act was implemented, and a decrease in the number of ED visits by uninsured patients, according to a study published in Annals of Emergency Medicine.
Researchers analyzed quarterly data on ED visits from the Agency for Healthcare Research and Quality’s Fast Stats database, which is an early-release, aggregated version of the State Emergency Department Databases and State Inpatient Databases. They compared changes in ED visits per capita and changes in share of ED visits by payer (Medicaid, uninsured, and private insurance) in states that did and did not expand Medicaid coverage in 2014.
The analysis included 25 states: 14 Medicaid expansion states (Arizona, California, Hawaii, Iowa, Illinois, Kentucky, Maryland, Minnesota, North Dakota, New Jersey, Nevada, New York, Rhode Island, and Vermont) and 11 nonexpansion states (Florida, Georgia, Indiana, Kansas, Missouri, North Carolina, Nebraska, South Carolina, South Dakota, Tennessee, and Wisconsin). Researchers defined visits that occurred during all 4 quarters of 2012 and the first 3 quarters of 2013 as the pre-expansion period, and visits from the first through fourth quarters of 2014 as the postexpansion period. Visits that occurred during the fourth quarter of 2013 were not included in the analysis because Medicaid coverage began to increase in the final quarter of 2013 for most states.
Overall, researchers found that after 2014, ED use per 1,000 people per quarter increased by 2.5 visits more in expansion states compared to nonexpansion states. Researchers estimated that 1.13 million ED visits in 2014 could be attributed to Medicaid expansion in these states. In expansion states, the share of ED visits by Medicaid patients increased by 8.8 percentage points and the share of visits by insured patients decreased by 5.3 percentage points, compared to nonexpansion states. The share of visits by insured patients did not change for expansion states but increased slightly for nonexpansion states.
An American College of Emergency Physicians press release about this study included editorial comments by Ari Friedman, MD, of Beth Israel Deaconess Medical Center in Boston, who said, “More emergency department visits by Medicaid beneficiaries is neither clearly bad nor clearly good. Insurance increases access to care, including emergency department care. We need to move beyond the value judgments that have dominated so much study of emergency department utilization towards a more rational basis for how we structure unscheduled visits in the health system. If we want to meet patients’ care needs as patients themselves define them, the emergency department has a key role to play in a flexible system.”
Nikpay S, Freedman S, Levy H, Buchmueller T. Effect of the Affordable Care Act Medicaid expansion on emergency department visits: evidence from state-level emergency department databases. Ann Emerg Med. 2017 June 26. [Epub ahead of print]. doi:http://dx.doi.org/10.1016/j.annemergmed.2017.03.023.
Child Firearm Suicide at Highest Rate in More Than a Decade
MOLLIE KALAYCIO
FRONTLINE MEDICAL NEWS
Boys, older children, and minorities are disproportionately affected when it comes to firearm injuries and deaths in US children and adolescents, and child firearm suicide rates are at the highest they have been in more than a decade, new study results revealed.
Approximately 19 children are either medically treated for a gunshot wound or killed by one every day in the United States. “The majority of these children are boys 13-17 years old, African American in the case of firearm homicide, and white and American Indian in the case of firearm suicide. Pediatric firearm injuries and deaths are an important public health problem in the United States, contributing substantially each year to premature death, illness, and disability of children,” said Katherine A. Fowler, PhD, of the National Center for Injury Prevention and Control, Atlanta, and her associates. “Finding ways to prevent such injuries and ensure that all children have safe, stable, nurturing relationships and environments remains one of our most important priorities.”
National data on fatal firearm injuries in 2011-2014 for this study were derived from death certificate data from the Centers for Disease Control and Prevention’s (CDC’s) National Vital Statistics System, obtained via the CDC’s Web-based Injury Statistics Query and Reporting System. Data on nonfatal firearm injuries for 2011-2014 were obtained from the National Electronic Injury Surveillance System.
“From 2012 to 2014, the average annual case fatality rate was 74% for firearm-related self-harm, 14% for firearm-related assaults, and 6% for unintentional firearm injuries,” the investigators reported.
Boys accounted for 82% of all child firearm deaths from 2012 to 2014. In this time period, the annual rate of firearm death for boys was 4.5 times higher than the annual rate for girls (2.8 vs. 0.6 per 100,000). This difference was even more pronounced by age, with the rate for 13- to 17-year-old boys being six times higher than the rate for same-aged girls. Similarly, boys suffer the majority of nonfatal firearm injuries treated in US EDs, accounting for 84% of all nonfatal firearm injuries medically treated each year from 2012 to 2014. The average annual rate of nonfatal firearm injuries for boys was five times the rate for girls at 13 vs. 3 per 100,000.
The annual rate of firearm homicide was 10 times higher among 13- to 17-year-olds vs. 0- to 12-year-olds (3 vs. 0.3 per 100,000). Unintentional firearm death rates were approximately twice as high when comparing these two groups (0.2 vs. 0.1 per 100,000).
Dr Fowler and her associates wrote, “Our findings indicate that most children who died of unintentional firearm injuries were shot by another child in their own age range and most often in the context of playing with a gun or showing it to others. More than one-third of the deaths of older children occurred in incidents in which the shooter thought that the gun was unloaded or thought that the safety was engaged.”
“Child firearm suicide rates showed a significant upward trend between 2007 and 2014, increasing 60% from 1.0 to 1.6 (P < .05) to the highest rate seen over the period examined,” Dr Fowler and her associates said.
Firearm suicide rates were 11 times higher among 13- to 17-year-olds vs. 10- to 12-year-olds (2 vs. 0.2 per 100,000). Older children also accounted for 88% of all nonfatal firearm injuries treated in an ED. The overall average annual rate of nonfatal firearm injuries for older children was 19 times that of younger children (24 vs. 1 per 100,000).
The annual firearm homicide rate for African American children was nearly 10 times higher than the rate for white children (4 vs. 0.4 per 100,000). However, the annual rate of firearm suicide among white children was nearly four times higher than the rate for African American children (2. vs. 0.6 per 100,000).
Awareness of the availability of firearms during times of crisis is crucial because suicides are often impulsive in young people, Dr Fowler and her associates said, “with previous findings indicating that many who attempt suicide spend 10 minutes or less deliberating. Safe storage practices (ie, unloading and locking all firearms and ammunition) can potentially be lifesaving in these instances,” as the results of previous studies in this age group attest.
Firearm deaths are the third leading cause of
Fowler KA, Dahlberg LL, Haileyesus T, Gutierrez C, Bacon S. Childhood firearm injuries in the united states. Pediatrics. 2017;140(1):e20163486.
BY JEFF BAUER
There was a substantial increase in the number of ED visits in states that expanded Medicaid coverage in 2014, after the Affordable Care Act was implemented, and a decrease in the number of ED visits by uninsured patients, according to a study published in Annals of Emergency Medicine.
Researchers analyzed quarterly data on ED visits from the Agency for Healthcare Research and Quality’s Fast Stats database, which is an early-release, aggregated version of the State Emergency Department Databases and State Inpatient Databases. They compared changes in ED visits per capita and changes in share of ED visits by payer (Medicaid, uninsured, and private insurance) in states that did and did not expand Medicaid coverage in 2014.
The analysis included 25 states: 14 Medicaid expansion states (Arizona, California, Hawaii, Iowa, Illinois, Kentucky, Maryland, Minnesota, North Dakota, New Jersey, Nevada, New York, Rhode Island, and Vermont) and 11 nonexpansion states (Florida, Georgia, Indiana, Kansas, Missouri, North Carolina, Nebraska, South Carolina, South Dakota, Tennessee, and Wisconsin). Researchers defined visits that occurred during all 4 quarters of 2012 and the first 3 quarters of 2013 as the pre-expansion period, and visits from the first through fourth quarters of 2014 as the postexpansion period. Visits that occurred during the fourth quarter of 2013 were not included in the analysis because Medicaid coverage began to increase in the final quarter of 2013 for most states.
Overall, researchers found that after 2014, ED use per 1,000 people per quarter increased by 2.5 visits more in expansion states compared to nonexpansion states. Researchers estimated that 1.13 million ED visits in 2014 could be attributed to Medicaid expansion in these states. In expansion states, the share of ED visits by Medicaid patients increased by 8.8 percentage points and the share of visits by insured patients decreased by 5.3 percentage points, compared to nonexpansion states. The share of visits by insured patients did not change for expansion states but increased slightly for nonexpansion states.
An American College of Emergency Physicians press release about this study included editorial comments by Ari Friedman, MD, of Beth Israel Deaconess Medical Center in Boston, who said, “More emergency department visits by Medicaid beneficiaries is neither clearly bad nor clearly good. Insurance increases access to care, including emergency department care. We need to move beyond the value judgments that have dominated so much study of emergency department utilization towards a more rational basis for how we structure unscheduled visits in the health system. If we want to meet patients’ care needs as patients themselves define them, the emergency department has a key role to play in a flexible system.”
Nikpay S, Freedman S, Levy H, Buchmueller T. Effect of the Affordable Care Act Medicaid expansion on emergency department visits: evidence from state-level emergency department databases. Ann Emerg Med. 2017 June 26. [Epub ahead of print]. doi:http://dx.doi.org/10.1016/j.annemergmed.2017.03.023.
Child Firearm Suicide at Highest Rate in More Than a Decade
MOLLIE KALAYCIO
FRONTLINE MEDICAL NEWS
Boys, older children, and minorities are disproportionately affected when it comes to firearm injuries and deaths in US children and adolescents, and child firearm suicide rates are at the highest they have been in more than a decade, new study results revealed.
Approximately 19 children are either medically treated for a gunshot wound or killed by one every day in the United States. “The majority of these children are boys 13-17 years old, African American in the case of firearm homicide, and white and American Indian in the case of firearm suicide. Pediatric firearm injuries and deaths are an important public health problem in the United States, contributing substantially each year to premature death, illness, and disability of children,” said Katherine A. Fowler, PhD, of the National Center for Injury Prevention and Control, Atlanta, and her associates. “Finding ways to prevent such injuries and ensure that all children have safe, stable, nurturing relationships and environments remains one of our most important priorities.”
National data on fatal firearm injuries in 2011-2014 for this study were derived from death certificate data from the Centers for Disease Control and Prevention’s (CDC’s) National Vital Statistics System, obtained via the CDC’s Web-based Injury Statistics Query and Reporting System. Data on nonfatal firearm injuries for 2011-2014 were obtained from the National Electronic Injury Surveillance System.
“From 2012 to 2014, the average annual case fatality rate was 74% for firearm-related self-harm, 14% for firearm-related assaults, and 6% for unintentional firearm injuries,” the investigators reported.
Boys accounted for 82% of all child firearm deaths from 2012 to 2014. In this time period, the annual rate of firearm death for boys was 4.5 times higher than the annual rate for girls (2.8 vs. 0.6 per 100,000). This difference was even more pronounced by age, with the rate for 13- to 17-year-old boys being six times higher than the rate for same-aged girls. Similarly, boys suffer the majority of nonfatal firearm injuries treated in US EDs, accounting for 84% of all nonfatal firearm injuries medically treated each year from 2012 to 2014. The average annual rate of nonfatal firearm injuries for boys was five times the rate for girls at 13 vs. 3 per 100,000.
The annual rate of firearm homicide was 10 times higher among 13- to 17-year-olds vs. 0- to 12-year-olds (3 vs. 0.3 per 100,000). Unintentional firearm death rates were approximately twice as high when comparing these two groups (0.2 vs. 0.1 per 100,000).
Dr Fowler and her associates wrote, “Our findings indicate that most children who died of unintentional firearm injuries were shot by another child in their own age range and most often in the context of playing with a gun or showing it to others. More than one-third of the deaths of older children occurred in incidents in which the shooter thought that the gun was unloaded or thought that the safety was engaged.”
“Child firearm suicide rates showed a significant upward trend between 2007 and 2014, increasing 60% from 1.0 to 1.6 (P < .05) to the highest rate seen over the period examined,” Dr Fowler and her associates said.
Firearm suicide rates were 11 times higher among 13- to 17-year-olds vs. 10- to 12-year-olds (2 vs. 0.2 per 100,000). Older children also accounted for 88% of all nonfatal firearm injuries treated in an ED. The overall average annual rate of nonfatal firearm injuries for older children was 19 times that of younger children (24 vs. 1 per 100,000).
The annual firearm homicide rate for African American children was nearly 10 times higher than the rate for white children (4 vs. 0.4 per 100,000). However, the annual rate of firearm suicide among white children was nearly four times higher than the rate for African American children (2. vs. 0.6 per 100,000).
Awareness of the availability of firearms during times of crisis is crucial because suicides are often impulsive in young people, Dr Fowler and her associates said, “with previous findings indicating that many who attempt suicide spend 10 minutes or less deliberating. Safe storage practices (ie, unloading and locking all firearms and ammunition) can potentially be lifesaving in these instances,” as the results of previous studies in this age group attest.
Firearm deaths are the third leading cause of
Fowler KA, Dahlberg LL, Haileyesus T, Gutierrez C, Bacon S. Childhood firearm injuries in the united states. Pediatrics. 2017;140(1):e20163486.
BY JEFF BAUER
There was a substantial increase in the number of ED visits in states that expanded Medicaid coverage in 2014, after the Affordable Care Act was implemented, and a decrease in the number of ED visits by uninsured patients, according to a study published in Annals of Emergency Medicine.
Researchers analyzed quarterly data on ED visits from the Agency for Healthcare Research and Quality’s Fast Stats database, which is an early-release, aggregated version of the State Emergency Department Databases and State Inpatient Databases. They compared changes in ED visits per capita and changes in share of ED visits by payer (Medicaid, uninsured, and private insurance) in states that did and did not expand Medicaid coverage in 2014.
The analysis included 25 states: 14 Medicaid expansion states (Arizona, California, Hawaii, Iowa, Illinois, Kentucky, Maryland, Minnesota, North Dakota, New Jersey, Nevada, New York, Rhode Island, and Vermont) and 11 nonexpansion states (Florida, Georgia, Indiana, Kansas, Missouri, North Carolina, Nebraska, South Carolina, South Dakota, Tennessee, and Wisconsin). Researchers defined visits that occurred during all 4 quarters of 2012 and the first 3 quarters of 2013 as the pre-expansion period, and visits from the first through fourth quarters of 2014 as the postexpansion period. Visits that occurred during the fourth quarter of 2013 were not included in the analysis because Medicaid coverage began to increase in the final quarter of 2013 for most states.
Overall, researchers found that after 2014, ED use per 1,000 people per quarter increased by 2.5 visits more in expansion states compared to nonexpansion states. Researchers estimated that 1.13 million ED visits in 2014 could be attributed to Medicaid expansion in these states. In expansion states, the share of ED visits by Medicaid patients increased by 8.8 percentage points and the share of visits by insured patients decreased by 5.3 percentage points, compared to nonexpansion states. The share of visits by insured patients did not change for expansion states but increased slightly for nonexpansion states.
An American College of Emergency Physicians press release about this study included editorial comments by Ari Friedman, MD, of Beth Israel Deaconess Medical Center in Boston, who said, “More emergency department visits by Medicaid beneficiaries is neither clearly bad nor clearly good. Insurance increases access to care, including emergency department care. We need to move beyond the value judgments that have dominated so much study of emergency department utilization towards a more rational basis for how we structure unscheduled visits in the health system. If we want to meet patients’ care needs as patients themselves define them, the emergency department has a key role to play in a flexible system.”
Nikpay S, Freedman S, Levy H, Buchmueller T. Effect of the Affordable Care Act Medicaid expansion on emergency department visits: evidence from state-level emergency department databases. Ann Emerg Med. 2017 June 26. [Epub ahead of print]. doi:http://dx.doi.org/10.1016/j.annemergmed.2017.03.023.
Child Firearm Suicide at Highest Rate in More Than a Decade
MOLLIE KALAYCIO
FRONTLINE MEDICAL NEWS
Boys, older children, and minorities are disproportionately affected when it comes to firearm injuries and deaths in US children and adolescents, and child firearm suicide rates are at the highest they have been in more than a decade, new study results revealed.
Approximately 19 children are either medically treated for a gunshot wound or killed by one every day in the United States. “The majority of these children are boys 13-17 years old, African American in the case of firearm homicide, and white and American Indian in the case of firearm suicide. Pediatric firearm injuries and deaths are an important public health problem in the United States, contributing substantially each year to premature death, illness, and disability of children,” said Katherine A. Fowler, PhD, of the National Center for Injury Prevention and Control, Atlanta, and her associates. “Finding ways to prevent such injuries and ensure that all children have safe, stable, nurturing relationships and environments remains one of our most important priorities.”
National data on fatal firearm injuries in 2011-2014 for this study were derived from death certificate data from the Centers for Disease Control and Prevention’s (CDC’s) National Vital Statistics System, obtained via the CDC’s Web-based Injury Statistics Query and Reporting System. Data on nonfatal firearm injuries for 2011-2014 were obtained from the National Electronic Injury Surveillance System.
“From 2012 to 2014, the average annual case fatality rate was 74% for firearm-related self-harm, 14% for firearm-related assaults, and 6% for unintentional firearm injuries,” the investigators reported.
Boys accounted for 82% of all child firearm deaths from 2012 to 2014. In this time period, the annual rate of firearm death for boys was 4.5 times higher than the annual rate for girls (2.8 vs. 0.6 per 100,000). This difference was even more pronounced by age, with the rate for 13- to 17-year-old boys being six times higher than the rate for same-aged girls. Similarly, boys suffer the majority of nonfatal firearm injuries treated in US EDs, accounting for 84% of all nonfatal firearm injuries medically treated each year from 2012 to 2014. The average annual rate of nonfatal firearm injuries for boys was five times the rate for girls at 13 vs. 3 per 100,000.
The annual rate of firearm homicide was 10 times higher among 13- to 17-year-olds vs. 0- to 12-year-olds (3 vs. 0.3 per 100,000). Unintentional firearm death rates were approximately twice as high when comparing these two groups (0.2 vs. 0.1 per 100,000).
Dr Fowler and her associates wrote, “Our findings indicate that most children who died of unintentional firearm injuries were shot by another child in their own age range and most often in the context of playing with a gun or showing it to others. More than one-third of the deaths of older children occurred in incidents in which the shooter thought that the gun was unloaded or thought that the safety was engaged.”
“Child firearm suicide rates showed a significant upward trend between 2007 and 2014, increasing 60% from 1.0 to 1.6 (P < .05) to the highest rate seen over the period examined,” Dr Fowler and her associates said.
Firearm suicide rates were 11 times higher among 13- to 17-year-olds vs. 10- to 12-year-olds (2 vs. 0.2 per 100,000). Older children also accounted for 88% of all nonfatal firearm injuries treated in an ED. The overall average annual rate of nonfatal firearm injuries for older children was 19 times that of younger children (24 vs. 1 per 100,000).
The annual firearm homicide rate for African American children was nearly 10 times higher than the rate for white children (4 vs. 0.4 per 100,000). However, the annual rate of firearm suicide among white children was nearly four times higher than the rate for African American children (2. vs. 0.6 per 100,000).
Awareness of the availability of firearms during times of crisis is crucial because suicides are often impulsive in young people, Dr Fowler and her associates said, “with previous findings indicating that many who attempt suicide spend 10 minutes or less deliberating. Safe storage practices (ie, unloading and locking all firearms and ammunition) can potentially be lifesaving in these instances,” as the results of previous studies in this age group attest.
Firearm deaths are the third leading cause of
Fowler KA, Dahlberg LL, Haileyesus T, Gutierrez C, Bacon S. Childhood firearm injuries in the united states. Pediatrics. 2017;140(1):e20163486.
U.S. goals for earlier HIV diagnosis and treatment may be out of reach
In 2015, only 66% of U.S. youth who were diagnosed with HIV in a Centers for Disease Control and Prevention program were introduced to proper care within 90 days of diagnosis, falling far short of the 2020 national goal to introduce 85% of HIV-affected youth to proper care within 30 days.
In an analysis of data from a CDC-funded program covering 61 state and local health departments and 123 community-based organizations in the United States, Puerto Rico, and the U.S. Virgin Islands, the CDC looked at HIV tests, new positive diagnoses, and linkage between patient and care within 90 days of diagnosis. Of 2,973 youths who were newly diagnosed with HIV, 1,955 (66%) were connected to care within 90 days, and 1,871 were interviewed for partner services, according to the CDC. Of 1,911 youths who had been previously diagnosed, 1,749 (92%) were not in medical care at the time of CDC testing.
“A health care provider’s testing recommendation is the most important predictor of testing among adolescents at risk for HIV infection,” the researchers said. “Increasing the number of HIV tests among youths at risk for HIV and increasing regular retesting among these youths is essential for reducing HIV infection in this vulnerable population.”
No conflicts of interest were reported by the authors.
Read more in MMWR (2017 Jun 23. doi: 10.15585/mmwr.mm6624a2).
In 2015, only 66% of U.S. youth who were diagnosed with HIV in a Centers for Disease Control and Prevention program were introduced to proper care within 90 days of diagnosis, falling far short of the 2020 national goal to introduce 85% of HIV-affected youth to proper care within 30 days.
In an analysis of data from a CDC-funded program covering 61 state and local health departments and 123 community-based organizations in the United States, Puerto Rico, and the U.S. Virgin Islands, the CDC looked at HIV tests, new positive diagnoses, and linkage between patient and care within 90 days of diagnosis. Of 2,973 youths who were newly diagnosed with HIV, 1,955 (66%) were connected to care within 90 days, and 1,871 were interviewed for partner services, according to the CDC. Of 1,911 youths who had been previously diagnosed, 1,749 (92%) were not in medical care at the time of CDC testing.
“A health care provider’s testing recommendation is the most important predictor of testing among adolescents at risk for HIV infection,” the researchers said. “Increasing the number of HIV tests among youths at risk for HIV and increasing regular retesting among these youths is essential for reducing HIV infection in this vulnerable population.”
No conflicts of interest were reported by the authors.
Read more in MMWR (2017 Jun 23. doi: 10.15585/mmwr.mm6624a2).
In 2015, only 66% of U.S. youth who were diagnosed with HIV in a Centers for Disease Control and Prevention program were introduced to proper care within 90 days of diagnosis, falling far short of the 2020 national goal to introduce 85% of HIV-affected youth to proper care within 30 days.
In an analysis of data from a CDC-funded program covering 61 state and local health departments and 123 community-based organizations in the United States, Puerto Rico, and the U.S. Virgin Islands, the CDC looked at HIV tests, new positive diagnoses, and linkage between patient and care within 90 days of diagnosis. Of 2,973 youths who were newly diagnosed with HIV, 1,955 (66%) were connected to care within 90 days, and 1,871 were interviewed for partner services, according to the CDC. Of 1,911 youths who had been previously diagnosed, 1,749 (92%) were not in medical care at the time of CDC testing.
“A health care provider’s testing recommendation is the most important predictor of testing among adolescents at risk for HIV infection,” the researchers said. “Increasing the number of HIV tests among youths at risk for HIV and increasing regular retesting among these youths is essential for reducing HIV infection in this vulnerable population.”
No conflicts of interest were reported by the authors.
Read more in MMWR (2017 Jun 23. doi: 10.15585/mmwr.mm6624a2).
FROM MMWR
Consider this probiotic for functional abdominal pain
In the article, “When can infants and children benefit from probiotics?” (J Fam Pract. 2016;65:789-794), Dassow et al recommended probiotics as a therapeutic tool for reducing abdominal pain associated with pediatric irritable bowel syndrome (IBS). There are several types of functional disorders in childhood with related abdominal pain, the most common of which are IBS and functional abdominal pain (FAP).1,2
Several recent randomized placebo-controlled trials—one of which I led—have shown that Lactobacillus reuteri DSM 17938 is a beneficial treatment for FAP in children.3-5 When compared with placebo, this probiotic agent significantly reduced the frequency and intensity of FAP in children.
Family physicians should consider this probiotic microorganism as a potential therapeutic tool for IBS, as well as childhood FAP.
Zvi Weizman, MD
Beer-Sheva, Israel
1. Childhood functional GI disorders: child/adolescent. In: Drossman DA CE, Delvaux M, Spiller RC, et al, eds. Rome III: the functional gastrointestinal disorders. 3rd ed. McLean, VA: Degnon Associates, Inc; 2006:895-897.
2. Brown LK, Beattie RM, Tighe MP. Practical management of functional abdominal pain in children. Arch Dis Child. 2016;101:677-683.
3. Romano C, Ferrau’ V, Cavataio F, et al. Lactobacillus reuteri in children with functional abdominal pain (FAP). J Paediatr Child Health. 2014;50:E68-E71.
4. Weizman Z, Abu-Abed J, Binsztok M. Lactobacillus reuteri DSM 17938 for the management of functional abdominal pain in childhood: A randomized, double-blind, placebo-controlled trial. J Pediatr. 2016;174:160-164.e1.
5. Jadrešin O, Hojsak I, Mišak Z, et al. Lactobacillus reuteri DSM 17938 in the treatment of functional abdominal pain in children - RCT study. J Pediatr Gastroenterol Nutr. 2017;64:925-929.
In the article, “When can infants and children benefit from probiotics?” (J Fam Pract. 2016;65:789-794), Dassow et al recommended probiotics as a therapeutic tool for reducing abdominal pain associated with pediatric irritable bowel syndrome (IBS). There are several types of functional disorders in childhood with related abdominal pain, the most common of which are IBS and functional abdominal pain (FAP).1,2
Several recent randomized placebo-controlled trials—one of which I led—have shown that Lactobacillus reuteri DSM 17938 is a beneficial treatment for FAP in children.3-5 When compared with placebo, this probiotic agent significantly reduced the frequency and intensity of FAP in children.
Family physicians should consider this probiotic microorganism as a potential therapeutic tool for IBS, as well as childhood FAP.
Zvi Weizman, MD
Beer-Sheva, Israel
In the article, “When can infants and children benefit from probiotics?” (J Fam Pract. 2016;65:789-794), Dassow et al recommended probiotics as a therapeutic tool for reducing abdominal pain associated with pediatric irritable bowel syndrome (IBS). There are several types of functional disorders in childhood with related abdominal pain, the most common of which are IBS and functional abdominal pain (FAP).1,2
Several recent randomized placebo-controlled trials—one of which I led—have shown that Lactobacillus reuteri DSM 17938 is a beneficial treatment for FAP in children.3-5 When compared with placebo, this probiotic agent significantly reduced the frequency and intensity of FAP in children.
Family physicians should consider this probiotic microorganism as a potential therapeutic tool for IBS, as well as childhood FAP.
Zvi Weizman, MD
Beer-Sheva, Israel
1. Childhood functional GI disorders: child/adolescent. In: Drossman DA CE, Delvaux M, Spiller RC, et al, eds. Rome III: the functional gastrointestinal disorders. 3rd ed. McLean, VA: Degnon Associates, Inc; 2006:895-897.
2. Brown LK, Beattie RM, Tighe MP. Practical management of functional abdominal pain in children. Arch Dis Child. 2016;101:677-683.
3. Romano C, Ferrau’ V, Cavataio F, et al. Lactobacillus reuteri in children with functional abdominal pain (FAP). J Paediatr Child Health. 2014;50:E68-E71.
4. Weizman Z, Abu-Abed J, Binsztok M. Lactobacillus reuteri DSM 17938 for the management of functional abdominal pain in childhood: A randomized, double-blind, placebo-controlled trial. J Pediatr. 2016;174:160-164.e1.
5. Jadrešin O, Hojsak I, Mišak Z, et al. Lactobacillus reuteri DSM 17938 in the treatment of functional abdominal pain in children - RCT study. J Pediatr Gastroenterol Nutr. 2017;64:925-929.
1. Childhood functional GI disorders: child/adolescent. In: Drossman DA CE, Delvaux M, Spiller RC, et al, eds. Rome III: the functional gastrointestinal disorders. 3rd ed. McLean, VA: Degnon Associates, Inc; 2006:895-897.
2. Brown LK, Beattie RM, Tighe MP. Practical management of functional abdominal pain in children. Arch Dis Child. 2016;101:677-683.
3. Romano C, Ferrau’ V, Cavataio F, et al. Lactobacillus reuteri in children with functional abdominal pain (FAP). J Paediatr Child Health. 2014;50:E68-E71.
4. Weizman Z, Abu-Abed J, Binsztok M. Lactobacillus reuteri DSM 17938 for the management of functional abdominal pain in childhood: A randomized, double-blind, placebo-controlled trial. J Pediatr. 2016;174:160-164.e1.
5. Jadrešin O, Hojsak I, Mišak Z, et al. Lactobacillus reuteri DSM 17938 in the treatment of functional abdominal pain in children - RCT study. J Pediatr Gastroenterol Nutr. 2017;64:925-929.
What effects—if any—does marijuana use during pregnancy have on the fetus or child?
EVIDENCE SUMMARY
A large systematic review of prospective and retrospective cohort studies found little or no effect of maternal marijuana use on birth weight, stillbirths, preterm births, or congenital anomalies (TABLE1-8). Some studies found lower birth weights and some found higher birth weights. The authors couldn’t perform a meta-analysis because of heterogeneity, but estimated a clinically insignificant difference of 100 g. Most studies were limited by failure to account for concurrent maternal tobacco smoking.
Moreover, all studies used interview data to determine maternal prenatal marijuana use, which can be subject to large recall bias. A multicenter prospective study of 585 pregnant women that compared interview data with serum screening to identify tetrahydrocannabinol (THC) found poor correlation between history and laboratory validation, for example.1 Only 31% of pregnant women with positive THC testing self-reported marijuana use (31% sensitivity), and only 43% of women who reported marijuana use had a positive THC screen (43% specificity). Most studies didn’t quantify marijuana use well and didn’t associate use with trimester of exposure.
The authors also point out that marijuana potency has increased substantially since the 1980s when many of the studies were done (THC content was 3.2% in 1983 and 13% in 2008); prenatal marijuana use in the present day may expose the fetus to larger amounts of THC.1
A 2016 retrospective cohort study of 56 mothers who reported prenatal marijuana use found no differences in preterm birth, low birth weight, or Apgar scores.2
Neurodevelopmental effects on infants, long-term effects on children, teens
Three prospective cohort studies evaluated neurodevelopmental outcomes in neonates and infants, and 2 studies continued to follow children into adolescence.1,3 All found essentially no differences associated with prenatal marijuana at birth, throughout infancy, and through age 3 years. The studies had the same limitations as those described previously (potential recall bias for identifying which children were exposed to marijuana prenatally and poorly quantified marijuana use not well-associated with trimester of exposure).
The Ottawa Prenatal Prospective Study (OPPS) examined 140 low-risk pregnancies in white women of higher socioeconomic status who used marijuana during pregnancy.1,3-7 Investigators considered: socioeconomic status, standard demographics, obstetric history, and use of other drugs, tobacco, and alcohol. Using a standardized newborn assessment scale, they found subtle behavioral differences at one week but not 9 days. Investigators evaluated children again at 3 years of age, school entry (5 or 6 years), and 9 to 12 years.
The Maternal Health Practices and Child Development study (MHPCD) of 564 high-risk pregnancies in predominantly minority women of low socioeconomic status followed infants from birth through 14 years of age.1,3-5,7,8 It found some small differences in outcomes among children exposed to marijuana prenatally. Of note, when investigators evaluated marijuana use at age 14 years, they compared adolescent self-report history with urine THC testing (specificity 78%).
The MHPCD study was limited because, compared with the nonusing group, mothers who used marijuana were also 20% to 25% more likely to be single and poor, to live in poorer quality homes, and to use alcohol, tobacco, and other drugs. Investigators used statistical modeling to account for these environmental differences and estimated that 10% of the difference in outcomes was attributable to prenatal marijuana exposure.
The Generation R study (Gen R) enrolled 220 lower-risk pregnancies in multiethnic European women of higher socioeconomic status, followed children to 3 years of age, and found no marijuana-associated differences in any parameter.1,3,4 The final assessment included only 51 children.
RECOMMENDATIONS
The American College of Obstetricians and Gynecologists (ACOG) recommends screening all women for tobacco, alcohol, and drug use (including marijuana) during early pregnancy.9 Women who report marijuana use should be counseled regarding potential adverse consequences to fetal health and be encouraged to discontinue use.
ACOG says that insufficient data exist to evaluate the effects of marijuana use on infants during lactation and breastfeeding and recommends against it.
The American Society of Addiction Medicine also recommends screening pregnant women for drug use and making appropriate referrals for substance use treatment.10
1. Metz TD, Stickrath EH. Marijuana use in pregnancy and lactation: a review of the evidence. Am J Obstet Gynecol. 2015;213:761-778.
2. Chabarria KC, Racusin DA, Antony KM, et al. Marijuana use and its effects in pregnancy. Am J Obstet Gynecol. 2016;215:506.e1-e7.
3. Warner TD, Roussos-Ross D, Behnke M. It’s not your mother’s marijuana: effects on maternal-fetal health and the developing child. Clinical Perinatology. 2014;41:877-894.
4. Huizink AC. Prenatal cannabis exposure and infant outcomes: overview of studies. Prog Neuro-Psychopharmacol Biol Psychiatry. 2014;52:45-52.
5. Goldschmidt L, Richardson GA, Willford J, et al. Prenatal marijuana exposure and intelligence test performance at age 6. J Am Acad Child Adolesc Psychiatry. 2008;47:254-263.
6. Fried PA. The Ottawa Prenatal Prospective Study (OPPS): methodological issues and findings—it’s easy to throw the baby out with the bath water. Life Sci. 1995;56:2159-2168.
7. Goldschmidt L, Day NL, Richardson GA. Effects of prenatal marijuana exposure on child behavior problems at age 10. Neurotoxicol Teratol. 2000;22:325-336.
8. Day NL, Goldschmidt L, Thomas CA. Prenatal marijuana exposure contributes to the prediction of marijuana use at age 14. Addiction. 2006;101:1313-1322.
9. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. Committee Opinion No. 637: Marijuana use during pregnancy and lactation. Obstet Gynecol. 2015;126:234-238.
10. American Society of Addiction Medicine. Public policy statement on women, alcohol and other drugs, and pregnancy. Chevy Chase MD: American Society of Addiction Medicine; 2011. Available at: http://www.asam.org/docs/default-source/public-policy-statements/1womenandpregnancy_7-11.pdf. Accessed July 5, 2016.
EVIDENCE SUMMARY
A large systematic review of prospective and retrospective cohort studies found little or no effect of maternal marijuana use on birth weight, stillbirths, preterm births, or congenital anomalies (TABLE1-8). Some studies found lower birth weights and some found higher birth weights. The authors couldn’t perform a meta-analysis because of heterogeneity, but estimated a clinically insignificant difference of 100 g. Most studies were limited by failure to account for concurrent maternal tobacco smoking.
Moreover, all studies used interview data to determine maternal prenatal marijuana use, which can be subject to large recall bias. A multicenter prospective study of 585 pregnant women that compared interview data with serum screening to identify tetrahydrocannabinol (THC) found poor correlation between history and laboratory validation, for example.1 Only 31% of pregnant women with positive THC testing self-reported marijuana use (31% sensitivity), and only 43% of women who reported marijuana use had a positive THC screen (43% specificity). Most studies didn’t quantify marijuana use well and didn’t associate use with trimester of exposure.
The authors also point out that marijuana potency has increased substantially since the 1980s when many of the studies were done (THC content was 3.2% in 1983 and 13% in 2008); prenatal marijuana use in the present day may expose the fetus to larger amounts of THC.1
A 2016 retrospective cohort study of 56 mothers who reported prenatal marijuana use found no differences in preterm birth, low birth weight, or Apgar scores.2
Neurodevelopmental effects on infants, long-term effects on children, teens
Three prospective cohort studies evaluated neurodevelopmental outcomes in neonates and infants, and 2 studies continued to follow children into adolescence.1,3 All found essentially no differences associated with prenatal marijuana at birth, throughout infancy, and through age 3 years. The studies had the same limitations as those described previously (potential recall bias for identifying which children were exposed to marijuana prenatally and poorly quantified marijuana use not well-associated with trimester of exposure).
The Ottawa Prenatal Prospective Study (OPPS) examined 140 low-risk pregnancies in white women of higher socioeconomic status who used marijuana during pregnancy.1,3-7 Investigators considered: socioeconomic status, standard demographics, obstetric history, and use of other drugs, tobacco, and alcohol. Using a standardized newborn assessment scale, they found subtle behavioral differences at one week but not 9 days. Investigators evaluated children again at 3 years of age, school entry (5 or 6 years), and 9 to 12 years.
The Maternal Health Practices and Child Development study (MHPCD) of 564 high-risk pregnancies in predominantly minority women of low socioeconomic status followed infants from birth through 14 years of age.1,3-5,7,8 It found some small differences in outcomes among children exposed to marijuana prenatally. Of note, when investigators evaluated marijuana use at age 14 years, they compared adolescent self-report history with urine THC testing (specificity 78%).
The MHPCD study was limited because, compared with the nonusing group, mothers who used marijuana were also 20% to 25% more likely to be single and poor, to live in poorer quality homes, and to use alcohol, tobacco, and other drugs. Investigators used statistical modeling to account for these environmental differences and estimated that 10% of the difference in outcomes was attributable to prenatal marijuana exposure.
The Generation R study (Gen R) enrolled 220 lower-risk pregnancies in multiethnic European women of higher socioeconomic status, followed children to 3 years of age, and found no marijuana-associated differences in any parameter.1,3,4 The final assessment included only 51 children.
RECOMMENDATIONS
The American College of Obstetricians and Gynecologists (ACOG) recommends screening all women for tobacco, alcohol, and drug use (including marijuana) during early pregnancy.9 Women who report marijuana use should be counseled regarding potential adverse consequences to fetal health and be encouraged to discontinue use.
ACOG says that insufficient data exist to evaluate the effects of marijuana use on infants during lactation and breastfeeding and recommends against it.
The American Society of Addiction Medicine also recommends screening pregnant women for drug use and making appropriate referrals for substance use treatment.10
EVIDENCE SUMMARY
A large systematic review of prospective and retrospective cohort studies found little or no effect of maternal marijuana use on birth weight, stillbirths, preterm births, or congenital anomalies (TABLE1-8). Some studies found lower birth weights and some found higher birth weights. The authors couldn’t perform a meta-analysis because of heterogeneity, but estimated a clinically insignificant difference of 100 g. Most studies were limited by failure to account for concurrent maternal tobacco smoking.
Moreover, all studies used interview data to determine maternal prenatal marijuana use, which can be subject to large recall bias. A multicenter prospective study of 585 pregnant women that compared interview data with serum screening to identify tetrahydrocannabinol (THC) found poor correlation between history and laboratory validation, for example.1 Only 31% of pregnant women with positive THC testing self-reported marijuana use (31% sensitivity), and only 43% of women who reported marijuana use had a positive THC screen (43% specificity). Most studies didn’t quantify marijuana use well and didn’t associate use with trimester of exposure.
The authors also point out that marijuana potency has increased substantially since the 1980s when many of the studies were done (THC content was 3.2% in 1983 and 13% in 2008); prenatal marijuana use in the present day may expose the fetus to larger amounts of THC.1
A 2016 retrospective cohort study of 56 mothers who reported prenatal marijuana use found no differences in preterm birth, low birth weight, or Apgar scores.2
Neurodevelopmental effects on infants, long-term effects on children, teens
Three prospective cohort studies evaluated neurodevelopmental outcomes in neonates and infants, and 2 studies continued to follow children into adolescence.1,3 All found essentially no differences associated with prenatal marijuana at birth, throughout infancy, and through age 3 years. The studies had the same limitations as those described previously (potential recall bias for identifying which children were exposed to marijuana prenatally and poorly quantified marijuana use not well-associated with trimester of exposure).
The Ottawa Prenatal Prospective Study (OPPS) examined 140 low-risk pregnancies in white women of higher socioeconomic status who used marijuana during pregnancy.1,3-7 Investigators considered: socioeconomic status, standard demographics, obstetric history, and use of other drugs, tobacco, and alcohol. Using a standardized newborn assessment scale, they found subtle behavioral differences at one week but not 9 days. Investigators evaluated children again at 3 years of age, school entry (5 or 6 years), and 9 to 12 years.
The Maternal Health Practices and Child Development study (MHPCD) of 564 high-risk pregnancies in predominantly minority women of low socioeconomic status followed infants from birth through 14 years of age.1,3-5,7,8 It found some small differences in outcomes among children exposed to marijuana prenatally. Of note, when investigators evaluated marijuana use at age 14 years, they compared adolescent self-report history with urine THC testing (specificity 78%).
The MHPCD study was limited because, compared with the nonusing group, mothers who used marijuana were also 20% to 25% more likely to be single and poor, to live in poorer quality homes, and to use alcohol, tobacco, and other drugs. Investigators used statistical modeling to account for these environmental differences and estimated that 10% of the difference in outcomes was attributable to prenatal marijuana exposure.
The Generation R study (Gen R) enrolled 220 lower-risk pregnancies in multiethnic European women of higher socioeconomic status, followed children to 3 years of age, and found no marijuana-associated differences in any parameter.1,3,4 The final assessment included only 51 children.
RECOMMENDATIONS
The American College of Obstetricians and Gynecologists (ACOG) recommends screening all women for tobacco, alcohol, and drug use (including marijuana) during early pregnancy.9 Women who report marijuana use should be counseled regarding potential adverse consequences to fetal health and be encouraged to discontinue use.
ACOG says that insufficient data exist to evaluate the effects of marijuana use on infants during lactation and breastfeeding and recommends against it.
The American Society of Addiction Medicine also recommends screening pregnant women for drug use and making appropriate referrals for substance use treatment.10
1. Metz TD, Stickrath EH. Marijuana use in pregnancy and lactation: a review of the evidence. Am J Obstet Gynecol. 2015;213:761-778.
2. Chabarria KC, Racusin DA, Antony KM, et al. Marijuana use and its effects in pregnancy. Am J Obstet Gynecol. 2016;215:506.e1-e7.
3. Warner TD, Roussos-Ross D, Behnke M. It’s not your mother’s marijuana: effects on maternal-fetal health and the developing child. Clinical Perinatology. 2014;41:877-894.
4. Huizink AC. Prenatal cannabis exposure and infant outcomes: overview of studies. Prog Neuro-Psychopharmacol Biol Psychiatry. 2014;52:45-52.
5. Goldschmidt L, Richardson GA, Willford J, et al. Prenatal marijuana exposure and intelligence test performance at age 6. J Am Acad Child Adolesc Psychiatry. 2008;47:254-263.
6. Fried PA. The Ottawa Prenatal Prospective Study (OPPS): methodological issues and findings—it’s easy to throw the baby out with the bath water. Life Sci. 1995;56:2159-2168.
7. Goldschmidt L, Day NL, Richardson GA. Effects of prenatal marijuana exposure on child behavior problems at age 10. Neurotoxicol Teratol. 2000;22:325-336.
8. Day NL, Goldschmidt L, Thomas CA. Prenatal marijuana exposure contributes to the prediction of marijuana use at age 14. Addiction. 2006;101:1313-1322.
9. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. Committee Opinion No. 637: Marijuana use during pregnancy and lactation. Obstet Gynecol. 2015;126:234-238.
10. American Society of Addiction Medicine. Public policy statement on women, alcohol and other drugs, and pregnancy. Chevy Chase MD: American Society of Addiction Medicine; 2011. Available at: http://www.asam.org/docs/default-source/public-policy-statements/1womenandpregnancy_7-11.pdf. Accessed July 5, 2016.
1. Metz TD, Stickrath EH. Marijuana use in pregnancy and lactation: a review of the evidence. Am J Obstet Gynecol. 2015;213:761-778.
2. Chabarria KC, Racusin DA, Antony KM, et al. Marijuana use and its effects in pregnancy. Am J Obstet Gynecol. 2016;215:506.e1-e7.
3. Warner TD, Roussos-Ross D, Behnke M. It’s not your mother’s marijuana: effects on maternal-fetal health and the developing child. Clinical Perinatology. 2014;41:877-894.
4. Huizink AC. Prenatal cannabis exposure and infant outcomes: overview of studies. Prog Neuro-Psychopharmacol Biol Psychiatry. 2014;52:45-52.
5. Goldschmidt L, Richardson GA, Willford J, et al. Prenatal marijuana exposure and intelligence test performance at age 6. J Am Acad Child Adolesc Psychiatry. 2008;47:254-263.
6. Fried PA. The Ottawa Prenatal Prospective Study (OPPS): methodological issues and findings—it’s easy to throw the baby out with the bath water. Life Sci. 1995;56:2159-2168.
7. Goldschmidt L, Day NL, Richardson GA. Effects of prenatal marijuana exposure on child behavior problems at age 10. Neurotoxicol Teratol. 2000;22:325-336.
8. Day NL, Goldschmidt L, Thomas CA. Prenatal marijuana exposure contributes to the prediction of marijuana use at age 14. Addiction. 2006;101:1313-1322.
9. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. Committee Opinion No. 637: Marijuana use during pregnancy and lactation. Obstet Gynecol. 2015;126:234-238.
10. American Society of Addiction Medicine. Public policy statement on women, alcohol and other drugs, and pregnancy. Chevy Chase MD: American Society of Addiction Medicine; 2011. Available at: http://www.asam.org/docs/default-source/public-policy-statements/1womenandpregnancy_7-11.pdf. Accessed July 5, 2016.
Evidence-based answers from the Family Physicians Inquiries Network
EVIDENCE-BASED ANSWER:
The effects are unclear. Marijuana use during pregnancy is associated with clinically unimportant lower birth weights (growth differences of approximately 100 g), but no differences in preterm births or congenital anomalies (strength of recommendation [SOR]: B, prospective and retrospective cohort studies with methodologic flaws).
Similarly, prenatal marijuana use isn’t associated with differences in neurodevelopmental outcomes (behavior problems, intellect, visual perception, language, or sustained attention and memory tasks) at birth, in the neonatal period, or in childhood through age 3 years. However, it may be associated with minimally lower verbal/quantitative IQ scores (1%) at age 6 years and increased impulsivity and hyperactivity (1%) at 10 years. Prenatal use isn’t linked to increased substance use at age 14 years (SOR: B, conflicting long-term prospective and retrospective cohort studies with methodologic flaws).
Study indicates parent-reported penicillin allergy in question
, according to David Vyles, DO, and his associates at the Medical College of Wisconsin, Milwaukee.
Because there is no process to safely and rapidly diagnose true penicillin allergy in a critical care setting, pediatric providers are reluctant to prescribe penicillin to children with a reported allergy. In this study, a three-tier penicillin testing process was used to evaluate the accuracy of a parent-reported penicillin allergy questionnaire in identifying children likely to be at low risk for penicillin allergy in an ED setting.
“Our results in the current study highlight that the high percentage of patients reporting a penicillin allergy to medical providers are likely inconsistent with true allergy,” concluded Dr. Vyles and his associates.
Read more at Pediatrics (2017. doi: 10.1542/peds.2017-0471).
, according to David Vyles, DO, and his associates at the Medical College of Wisconsin, Milwaukee.
Because there is no process to safely and rapidly diagnose true penicillin allergy in a critical care setting, pediatric providers are reluctant to prescribe penicillin to children with a reported allergy. In this study, a three-tier penicillin testing process was used to evaluate the accuracy of a parent-reported penicillin allergy questionnaire in identifying children likely to be at low risk for penicillin allergy in an ED setting.
“Our results in the current study highlight that the high percentage of patients reporting a penicillin allergy to medical providers are likely inconsistent with true allergy,” concluded Dr. Vyles and his associates.
Read more at Pediatrics (2017. doi: 10.1542/peds.2017-0471).
, according to David Vyles, DO, and his associates at the Medical College of Wisconsin, Milwaukee.
Because there is no process to safely and rapidly diagnose true penicillin allergy in a critical care setting, pediatric providers are reluctant to prescribe penicillin to children with a reported allergy. In this study, a three-tier penicillin testing process was used to evaluate the accuracy of a parent-reported penicillin allergy questionnaire in identifying children likely to be at low risk for penicillin allergy in an ED setting.
“Our results in the current study highlight that the high percentage of patients reporting a penicillin allergy to medical providers are likely inconsistent with true allergy,” concluded Dr. Vyles and his associates.
Read more at Pediatrics (2017. doi: 10.1542/peds.2017-0471).
FROM PEDIATRICS
Daily probiotics have no effect on infections causing child care absences
Results of a double-blind, placebo-controlled study do not support use of probiotics to prevent upper respiratory and gastrointestinal infections in children aged 8-14 months at enrollment, as the probiotics did not reduce infection-related child care absences.
In the study of 290 Danish infants randomly allocated to receive a placebo or a combination of Bifidobacterium animalis subsp lactis (BB-12) and Lactobacillus rhamnosus (LGG) in a dose of 109 colony-forming units of each daily for a 6-month intervention period, there were no differences in absences from child care between the two groups (1.14 days; 95% confidence interval, −0.55 to 2.82), reported Rikke Pilmann Laursen, MSc, and her associates at the University of Copenhagen (Pediatrics. 2017. doi: 10.1542/peds.2017-0735).
Infants were a mean 10 months old at baseline, and 47% were still breastfeeding. The mean age at breastfeeding discontinuation was 12 months.
In terms of the number of children with one or more episodes of an upper respiratory tract infection, the LGG and BB-12 vs. placebo odds ratio was 1.22 (95% CI, 0.74-2.00; P = .43). The number of children with one or more episodes of diarrhea in the LGG and BB-12 vs. placebo odds ratio was 1.42 (95% CI, 0.88-2.32; P = .15).
The effect of probiotics in preventing infections in preschool-aged children has been explored in several studies and recent reviews, suggesting an effect specifically on upper respiratory tract and GI infections in small children. This study diverges in that it examined the effect of a combination of probiotics on absences from child care related to those infections in infants aged 8-14 months at the time of enrollment, whereas previous studies focused on children older than 1 year.
This study was funded by Innovation Fund Denmark, the University of Copenhagen, and Chr Hansen A/S. Dr. Kim Fleischer Michaelsen and Dr. Christian Mølgaard received a grant from Chr Hansen for the current study. None of the other investigators had any relevant financial disclosures.
Any intervention that can prevent child care–associated illnesses can have economic and educational implications, as well as public health ones. However, in the Laursen et al. study, almost 47% of the infants enrolled were breastfed, as opposed to previous studies in which the children participating generally were over 1 year old.
Given the positive effects of breastfeeding in preventing infections and the high percentage of infants who were breastfed in this study, it may be harder to distinguish the effects of the probiotic supplement in the Laursen et al. study. Indirectly, this study suggests additional information on the relative value of a probiotic intervention, compared with breastfeeding and diet, is warranted, and perhaps there is another reason to encourage breastfeeding as long as possible.
Michael D. Cabana, MD, MPH, is a professor of pediatrics, epidemiology and biostatistics and a member of the faculty at the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco. Daniel J. Merenstein, MD, is an associate professor of family medicine at Georgetown University, Washington. Pharmavite, Bayer, and Sanofi have provided Georgetown University with consulting funding. Both physicians, who commented in an editorial accompanying the article by Laursen et al. (Pediatrics. 2017. doi: 10.1542/peds.2017-1729), disclosed no financial relationships relevant to this article. Dr. Merenstein has been an expert witness for Proctor & Gamble while Dr. Cabana has served as a consultant for BioGaia, Nestle, Mead Johnson, and Wyeth.
Any intervention that can prevent child care–associated illnesses can have economic and educational implications, as well as public health ones. However, in the Laursen et al. study, almost 47% of the infants enrolled were breastfed, as opposed to previous studies in which the children participating generally were over 1 year old.
Given the positive effects of breastfeeding in preventing infections and the high percentage of infants who were breastfed in this study, it may be harder to distinguish the effects of the probiotic supplement in the Laursen et al. study. Indirectly, this study suggests additional information on the relative value of a probiotic intervention, compared with breastfeeding and diet, is warranted, and perhaps there is another reason to encourage breastfeeding as long as possible.
Michael D. Cabana, MD, MPH, is a professor of pediatrics, epidemiology and biostatistics and a member of the faculty at the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco. Daniel J. Merenstein, MD, is an associate professor of family medicine at Georgetown University, Washington. Pharmavite, Bayer, and Sanofi have provided Georgetown University with consulting funding. Both physicians, who commented in an editorial accompanying the article by Laursen et al. (Pediatrics. 2017. doi: 10.1542/peds.2017-1729), disclosed no financial relationships relevant to this article. Dr. Merenstein has been an expert witness for Proctor & Gamble while Dr. Cabana has served as a consultant for BioGaia, Nestle, Mead Johnson, and Wyeth.
Any intervention that can prevent child care–associated illnesses can have economic and educational implications, as well as public health ones. However, in the Laursen et al. study, almost 47% of the infants enrolled were breastfed, as opposed to previous studies in which the children participating generally were over 1 year old.
Given the positive effects of breastfeeding in preventing infections and the high percentage of infants who were breastfed in this study, it may be harder to distinguish the effects of the probiotic supplement in the Laursen et al. study. Indirectly, this study suggests additional information on the relative value of a probiotic intervention, compared with breastfeeding and diet, is warranted, and perhaps there is another reason to encourage breastfeeding as long as possible.
Michael D. Cabana, MD, MPH, is a professor of pediatrics, epidemiology and biostatistics and a member of the faculty at the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco. Daniel J. Merenstein, MD, is an associate professor of family medicine at Georgetown University, Washington. Pharmavite, Bayer, and Sanofi have provided Georgetown University with consulting funding. Both physicians, who commented in an editorial accompanying the article by Laursen et al. (Pediatrics. 2017. doi: 10.1542/peds.2017-1729), disclosed no financial relationships relevant to this article. Dr. Merenstein has been an expert witness for Proctor & Gamble while Dr. Cabana has served as a consultant for BioGaia, Nestle, Mead Johnson, and Wyeth.
Results of a double-blind, placebo-controlled study do not support use of probiotics to prevent upper respiratory and gastrointestinal infections in children aged 8-14 months at enrollment, as the probiotics did not reduce infection-related child care absences.
In the study of 290 Danish infants randomly allocated to receive a placebo or a combination of Bifidobacterium animalis subsp lactis (BB-12) and Lactobacillus rhamnosus (LGG) in a dose of 109 colony-forming units of each daily for a 6-month intervention period, there were no differences in absences from child care between the two groups (1.14 days; 95% confidence interval, −0.55 to 2.82), reported Rikke Pilmann Laursen, MSc, and her associates at the University of Copenhagen (Pediatrics. 2017. doi: 10.1542/peds.2017-0735).
Infants were a mean 10 months old at baseline, and 47% were still breastfeeding. The mean age at breastfeeding discontinuation was 12 months.
In terms of the number of children with one or more episodes of an upper respiratory tract infection, the LGG and BB-12 vs. placebo odds ratio was 1.22 (95% CI, 0.74-2.00; P = .43). The number of children with one or more episodes of diarrhea in the LGG and BB-12 vs. placebo odds ratio was 1.42 (95% CI, 0.88-2.32; P = .15).
The effect of probiotics in preventing infections in preschool-aged children has been explored in several studies and recent reviews, suggesting an effect specifically on upper respiratory tract and GI infections in small children. This study diverges in that it examined the effect of a combination of probiotics on absences from child care related to those infections in infants aged 8-14 months at the time of enrollment, whereas previous studies focused on children older than 1 year.
This study was funded by Innovation Fund Denmark, the University of Copenhagen, and Chr Hansen A/S. Dr. Kim Fleischer Michaelsen and Dr. Christian Mølgaard received a grant from Chr Hansen for the current study. None of the other investigators had any relevant financial disclosures.
Results of a double-blind, placebo-controlled study do not support use of probiotics to prevent upper respiratory and gastrointestinal infections in children aged 8-14 months at enrollment, as the probiotics did not reduce infection-related child care absences.
In the study of 290 Danish infants randomly allocated to receive a placebo or a combination of Bifidobacterium animalis subsp lactis (BB-12) and Lactobacillus rhamnosus (LGG) in a dose of 109 colony-forming units of each daily for a 6-month intervention period, there were no differences in absences from child care between the two groups (1.14 days; 95% confidence interval, −0.55 to 2.82), reported Rikke Pilmann Laursen, MSc, and her associates at the University of Copenhagen (Pediatrics. 2017. doi: 10.1542/peds.2017-0735).
Infants were a mean 10 months old at baseline, and 47% were still breastfeeding. The mean age at breastfeeding discontinuation was 12 months.
In terms of the number of children with one or more episodes of an upper respiratory tract infection, the LGG and BB-12 vs. placebo odds ratio was 1.22 (95% CI, 0.74-2.00; P = .43). The number of children with one or more episodes of diarrhea in the LGG and BB-12 vs. placebo odds ratio was 1.42 (95% CI, 0.88-2.32; P = .15).
The effect of probiotics in preventing infections in preschool-aged children has been explored in several studies and recent reviews, suggesting an effect specifically on upper respiratory tract and GI infections in small children. This study diverges in that it examined the effect of a combination of probiotics on absences from child care related to those infections in infants aged 8-14 months at the time of enrollment, whereas previous studies focused on children older than 1 year.
This study was funded by Innovation Fund Denmark, the University of Copenhagen, and Chr Hansen A/S. Dr. Kim Fleischer Michaelsen and Dr. Christian Mølgaard received a grant from Chr Hansen for the current study. None of the other investigators had any relevant financial disclosures.
FROM PEDIATRICS
Key clinical point:
Major finding: Intention-to-treat analysis showed no difference between the probiotics and placebo study groups.
Data source: A randomized, double-blind, placebo-controlled study of 290 infants aged 8-14 months at enrollment.
Disclosures: This study was funded by Innovation Fund Denmark, the University of Copenhagen, and Chr Hansen A/S. Dr. Kim Fleischer Michaelsen and Dr. Christian Mølgaard received a grant from Chr Hansen for the current study. None of the other investigators had any relevant financial disclosures.
‘Chronic Lyme’: Serious bacterial infections reported with unproven treatments
Unproven treatments for so-called chronic Lyme disease can cause serious, even fatal, complications, according to five case reports published in the Morbidity and Mortality Weekly Report.
“Patients, clinicians, and public health practitioners should be aware that treatments for chronic Lyme disease can carry serious risks,” the authors wrote.
Chronic Lyme disease is a nonspecific diagnosis that has no consistent definition. Some clinicians use this label for patients who have a variety of debilitating conditions such as fatigue, generalized pain, and neurologic symptoms, even in the absence of laboratory evidence of Borrelia burgdorferi infection, objective signs of infection, or a history of tick exposure. People who support this diagnosis mistakenly believe that B. burgdorferi can cause longstanding disabling symptoms even when standard testing for the organism is negative, when the truth is that tests for the organism become more sensitive the longer the infection persists, according to Natalie S. Marzec, MD, a resident in preventive medicine at the University of Colorado, Aurora, and her associates.
Patients who cannot obtain symptom relief with conventional clinicians may consult “practitioners who might identify themselves as Lyme disease specialists (‘Lyme literate’ doctors) or from complementary and alternative medicine clinics,” where they are diagnosed with chronic Lyme disease. Such patients have been offered unproven treatments, including extended courses of intravenous antibiotics, infusions of hydrogen peroxide, immunoglobulin therapy, hyperbaric oxygen treatment, electromagnetic frequency therapy, garlic supplements, colloidal silver, and stem-cell transplantation.
Dr. Marzec and her associates presented case reports of five such patients diagnosed with chronic Lyme disease who sustained serious harm from such treatments (MMWR 2017;66[23]:607-9).
A woman in her late 30s with fatigue and joint pain was given a peripherally inserted central catheter (PICC) for IV delivery of ceftriaxone and cefotaxime. After 3 weeks, she developed fever, rash, hypotension, and tachycardia. In the intensive care unit (ICU), she was given broad-spectrum IV antibiotics and vasopressors, and was mechanically ventilated, but died of septic shock related to catheter-associated bacteremia.
An adolescent was told at an alternative medicine clinic that her years of muscle and joint pain, backaches, headaches, and lethargy were due to chronic Lyme disease. A PICC was placed to deliver IV antibiotics for 5 months. She developed pallor, chills, fever, hypotension, and tachycardia consistent with septic shock. Cultures demonstrated Acinetobacter species in her blood and on the PICC, and she required several weeks of ICU care.
A woman in her late 40s was diagnosed as having chronic Lyme disease based on unvalidated tests and was treated for months with intramuscular penicillin, IV ceftriazone, and IV azithromycin administered through a tunneled IV catheter; as well as doxycycline, and the antiparasitic drug tinidazole. She was hospitalized for back pain, shortness of breath, and malaise, and cultures of the catheter and her blood yielded Pseudomonas aeruginosa. She was found to have osteodiscitis caused by the same organism, with destruction of the 9th and 10th vertebrae, and was treated, and her back pain eventually improved.
A woman in her 50s was diagnosed as having amyotrophic lateral sclerosis, but sought a second opinion and was told that she had chronic Lyme disease (along with babesiosis, and Rocky Mountain spotted fever). She was treated with herbs and homeopathic remedies, followed by intensive antimicrobial and antiviral therapies. She developed intractable Clostridium difficile colitis that lasted for 2 years until she died from complications related to amyotrophic lateral sclerosis.
A woman in her 60s who had autoimmune neutropenia, mixed connective tissue disease, and degenerative arthritis was told her neuropathy was due to chronic Lyme disease. She was treated with immunoglobulin administered through an implanted subcutaneous port. After years of treatments, she was hospitalized for fever and back pain, had blood cultures positive for methicillin-sensitive Staphylococcus aureus, was found to have inflammation of the lumbar facet joints, epidural space, and paraspinal muscles – and eventually required surgical drainage of a paraspinal abscess.
“These cases highlight the severity and scope of adverse effects that can be caused by the use of unproven treatments for chronic Lyme disease,” Dr. Marzec and her associates said.
This work was supported by the CDC. Dr. Marzec and her associates reported having no relevant financial disclosures.
Unproven treatments for so-called chronic Lyme disease can cause serious, even fatal, complications, according to five case reports published in the Morbidity and Mortality Weekly Report.
“Patients, clinicians, and public health practitioners should be aware that treatments for chronic Lyme disease can carry serious risks,” the authors wrote.
Chronic Lyme disease is a nonspecific diagnosis that has no consistent definition. Some clinicians use this label for patients who have a variety of debilitating conditions such as fatigue, generalized pain, and neurologic symptoms, even in the absence of laboratory evidence of Borrelia burgdorferi infection, objective signs of infection, or a history of tick exposure. People who support this diagnosis mistakenly believe that B. burgdorferi can cause longstanding disabling symptoms even when standard testing for the organism is negative, when the truth is that tests for the organism become more sensitive the longer the infection persists, according to Natalie S. Marzec, MD, a resident in preventive medicine at the University of Colorado, Aurora, and her associates.
Patients who cannot obtain symptom relief with conventional clinicians may consult “practitioners who might identify themselves as Lyme disease specialists (‘Lyme literate’ doctors) or from complementary and alternative medicine clinics,” where they are diagnosed with chronic Lyme disease. Such patients have been offered unproven treatments, including extended courses of intravenous antibiotics, infusions of hydrogen peroxide, immunoglobulin therapy, hyperbaric oxygen treatment, electromagnetic frequency therapy, garlic supplements, colloidal silver, and stem-cell transplantation.
Dr. Marzec and her associates presented case reports of five such patients diagnosed with chronic Lyme disease who sustained serious harm from such treatments (MMWR 2017;66[23]:607-9).
A woman in her late 30s with fatigue and joint pain was given a peripherally inserted central catheter (PICC) for IV delivery of ceftriaxone and cefotaxime. After 3 weeks, she developed fever, rash, hypotension, and tachycardia. In the intensive care unit (ICU), she was given broad-spectrum IV antibiotics and vasopressors, and was mechanically ventilated, but died of septic shock related to catheter-associated bacteremia.
An adolescent was told at an alternative medicine clinic that her years of muscle and joint pain, backaches, headaches, and lethargy were due to chronic Lyme disease. A PICC was placed to deliver IV antibiotics for 5 months. She developed pallor, chills, fever, hypotension, and tachycardia consistent with septic shock. Cultures demonstrated Acinetobacter species in her blood and on the PICC, and she required several weeks of ICU care.
A woman in her late 40s was diagnosed as having chronic Lyme disease based on unvalidated tests and was treated for months with intramuscular penicillin, IV ceftriazone, and IV azithromycin administered through a tunneled IV catheter; as well as doxycycline, and the antiparasitic drug tinidazole. She was hospitalized for back pain, shortness of breath, and malaise, and cultures of the catheter and her blood yielded Pseudomonas aeruginosa. She was found to have osteodiscitis caused by the same organism, with destruction of the 9th and 10th vertebrae, and was treated, and her back pain eventually improved.
A woman in her 50s was diagnosed as having amyotrophic lateral sclerosis, but sought a second opinion and was told that she had chronic Lyme disease (along with babesiosis, and Rocky Mountain spotted fever). She was treated with herbs and homeopathic remedies, followed by intensive antimicrobial and antiviral therapies. She developed intractable Clostridium difficile colitis that lasted for 2 years until she died from complications related to amyotrophic lateral sclerosis.
A woman in her 60s who had autoimmune neutropenia, mixed connective tissue disease, and degenerative arthritis was told her neuropathy was due to chronic Lyme disease. She was treated with immunoglobulin administered through an implanted subcutaneous port. After years of treatments, she was hospitalized for fever and back pain, had blood cultures positive for methicillin-sensitive Staphylococcus aureus, was found to have inflammation of the lumbar facet joints, epidural space, and paraspinal muscles – and eventually required surgical drainage of a paraspinal abscess.
“These cases highlight the severity and scope of adverse effects that can be caused by the use of unproven treatments for chronic Lyme disease,” Dr. Marzec and her associates said.
This work was supported by the CDC. Dr. Marzec and her associates reported having no relevant financial disclosures.
Unproven treatments for so-called chronic Lyme disease can cause serious, even fatal, complications, according to five case reports published in the Morbidity and Mortality Weekly Report.
“Patients, clinicians, and public health practitioners should be aware that treatments for chronic Lyme disease can carry serious risks,” the authors wrote.
Chronic Lyme disease is a nonspecific diagnosis that has no consistent definition. Some clinicians use this label for patients who have a variety of debilitating conditions such as fatigue, generalized pain, and neurologic symptoms, even in the absence of laboratory evidence of Borrelia burgdorferi infection, objective signs of infection, or a history of tick exposure. People who support this diagnosis mistakenly believe that B. burgdorferi can cause longstanding disabling symptoms even when standard testing for the organism is negative, when the truth is that tests for the organism become more sensitive the longer the infection persists, according to Natalie S. Marzec, MD, a resident in preventive medicine at the University of Colorado, Aurora, and her associates.
Patients who cannot obtain symptom relief with conventional clinicians may consult “practitioners who might identify themselves as Lyme disease specialists (‘Lyme literate’ doctors) or from complementary and alternative medicine clinics,” where they are diagnosed with chronic Lyme disease. Such patients have been offered unproven treatments, including extended courses of intravenous antibiotics, infusions of hydrogen peroxide, immunoglobulin therapy, hyperbaric oxygen treatment, electromagnetic frequency therapy, garlic supplements, colloidal silver, and stem-cell transplantation.
Dr. Marzec and her associates presented case reports of five such patients diagnosed with chronic Lyme disease who sustained serious harm from such treatments (MMWR 2017;66[23]:607-9).
A woman in her late 30s with fatigue and joint pain was given a peripherally inserted central catheter (PICC) for IV delivery of ceftriaxone and cefotaxime. After 3 weeks, she developed fever, rash, hypotension, and tachycardia. In the intensive care unit (ICU), she was given broad-spectrum IV antibiotics and vasopressors, and was mechanically ventilated, but died of septic shock related to catheter-associated bacteremia.
An adolescent was told at an alternative medicine clinic that her years of muscle and joint pain, backaches, headaches, and lethargy were due to chronic Lyme disease. A PICC was placed to deliver IV antibiotics for 5 months. She developed pallor, chills, fever, hypotension, and tachycardia consistent with septic shock. Cultures demonstrated Acinetobacter species in her blood and on the PICC, and she required several weeks of ICU care.
A woman in her late 40s was diagnosed as having chronic Lyme disease based on unvalidated tests and was treated for months with intramuscular penicillin, IV ceftriazone, and IV azithromycin administered through a tunneled IV catheter; as well as doxycycline, and the antiparasitic drug tinidazole. She was hospitalized for back pain, shortness of breath, and malaise, and cultures of the catheter and her blood yielded Pseudomonas aeruginosa. She was found to have osteodiscitis caused by the same organism, with destruction of the 9th and 10th vertebrae, and was treated, and her back pain eventually improved.
A woman in her 50s was diagnosed as having amyotrophic lateral sclerosis, but sought a second opinion and was told that she had chronic Lyme disease (along with babesiosis, and Rocky Mountain spotted fever). She was treated with herbs and homeopathic remedies, followed by intensive antimicrobial and antiviral therapies. She developed intractable Clostridium difficile colitis that lasted for 2 years until she died from complications related to amyotrophic lateral sclerosis.
A woman in her 60s who had autoimmune neutropenia, mixed connective tissue disease, and degenerative arthritis was told her neuropathy was due to chronic Lyme disease. She was treated with immunoglobulin administered through an implanted subcutaneous port. After years of treatments, she was hospitalized for fever and back pain, had blood cultures positive for methicillin-sensitive Staphylococcus aureus, was found to have inflammation of the lumbar facet joints, epidural space, and paraspinal muscles – and eventually required surgical drainage of a paraspinal abscess.
“These cases highlight the severity and scope of adverse effects that can be caused by the use of unproven treatments for chronic Lyme disease,” Dr. Marzec and her associates said.
This work was supported by the CDC. Dr. Marzec and her associates reported having no relevant financial disclosures.
FROM MMWR
Key clinical point: Unproven treatments for so-called chronic Lyme disease cause serious, even fatal, complications.
Major finding:
Data source: Five case reports submitted to the CDC by clinicians, health departments, and individual patients.
Disclosures: This work was supported by the CDC. Dr. Marzec and her associates reported having no relevant financial disclosures.
Not so fast
If you are a busy primary care physician, wouldn’t you like to get some quick confirmation that your patient with a fever and runny nose has a viral upper respiratory infection? If there were a test or a simple physical finding that could give you the answer while the patient was still in the office, you could dispense a quick dose of reassurance and send him or her on their way. It would probably help you inch a bit closer to relieving the congestion in your waiting room.
I am sure most of you realize that relying on the patient’s temperature or the color of his or her nasal mucus is not going to give you that reliable and swift answer you would like. There have been rapid diagnostic tests for influenza on the market for several years, but I have not been aware of a similar test for rhinovirus. But I recently came across a study that offers some hope that such a test might become a reality in the future (EBioMedicine. 2017 Mar;17:172-81). In the study, researchers at Duke University and elsewhere identified a group of proteins in mucus that can confirm – with 86% accuracy – that the patient is infected with a cold or flu virus. They anticipate that this discovery could be adapted into a rapid test that could be performed in the doctor’s office.
However, I am sure that most of you would do a careful exam and spend a few minutes on a slightly more detailed discussion of what worrisome symptoms the parents should be watching for. But let’s be honest. Isn’t it likely that knowing that the patient has a rhinovirus infection might derail your diagnostic process short of a full consideration? Isn’t it tempting to say to yourself, “He only has a viral URI, and I even know the name of the virus. My job is done.”
Although the odds are that the virus is causing all your patient’s symptoms, there is always the chance that he or she is harboring a bacterial coinfection. Or, that what appears to be “only” a virus is actually an early step in the deadly spiral of the first episode of diabetic ketoacidosis.
This quandary is another example of the paradox in which more information can make your job as a diagnostician more difficult. Does your patient’s positive rapid strep test mean that strep is the primary cause of your patient’s fever and sore throat? Couldn’t he or she just be a carrier? Should a positive test that confirms your clinical impression put an end to your evaluation of the patient?
You could answer that you don’t have the time to go looking for zebra stripes hidden on the underbelly of every equine that gallops into your exam room. Of course you don’t. But, you are obligated to keep your mind open to the possibility that a lab test promising to make your job easy may not be telling you the whole story.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
If you are a busy primary care physician, wouldn’t you like to get some quick confirmation that your patient with a fever and runny nose has a viral upper respiratory infection? If there were a test or a simple physical finding that could give you the answer while the patient was still in the office, you could dispense a quick dose of reassurance and send him or her on their way. It would probably help you inch a bit closer to relieving the congestion in your waiting room.
I am sure most of you realize that relying on the patient’s temperature or the color of his or her nasal mucus is not going to give you that reliable and swift answer you would like. There have been rapid diagnostic tests for influenza on the market for several years, but I have not been aware of a similar test for rhinovirus. But I recently came across a study that offers some hope that such a test might become a reality in the future (EBioMedicine. 2017 Mar;17:172-81). In the study, researchers at Duke University and elsewhere identified a group of proteins in mucus that can confirm – with 86% accuracy – that the patient is infected with a cold or flu virus. They anticipate that this discovery could be adapted into a rapid test that could be performed in the doctor’s office.
However, I am sure that most of you would do a careful exam and spend a few minutes on a slightly more detailed discussion of what worrisome symptoms the parents should be watching for. But let’s be honest. Isn’t it likely that knowing that the patient has a rhinovirus infection might derail your diagnostic process short of a full consideration? Isn’t it tempting to say to yourself, “He only has a viral URI, and I even know the name of the virus. My job is done.”
Although the odds are that the virus is causing all your patient’s symptoms, there is always the chance that he or she is harboring a bacterial coinfection. Or, that what appears to be “only” a virus is actually an early step in the deadly spiral of the first episode of diabetic ketoacidosis.
This quandary is another example of the paradox in which more information can make your job as a diagnostician more difficult. Does your patient’s positive rapid strep test mean that strep is the primary cause of your patient’s fever and sore throat? Couldn’t he or she just be a carrier? Should a positive test that confirms your clinical impression put an end to your evaluation of the patient?
You could answer that you don’t have the time to go looking for zebra stripes hidden on the underbelly of every equine that gallops into your exam room. Of course you don’t. But, you are obligated to keep your mind open to the possibility that a lab test promising to make your job easy may not be telling you the whole story.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
If you are a busy primary care physician, wouldn’t you like to get some quick confirmation that your patient with a fever and runny nose has a viral upper respiratory infection? If there were a test or a simple physical finding that could give you the answer while the patient was still in the office, you could dispense a quick dose of reassurance and send him or her on their way. It would probably help you inch a bit closer to relieving the congestion in your waiting room.
I am sure most of you realize that relying on the patient’s temperature or the color of his or her nasal mucus is not going to give you that reliable and swift answer you would like. There have been rapid diagnostic tests for influenza on the market for several years, but I have not been aware of a similar test for rhinovirus. But I recently came across a study that offers some hope that such a test might become a reality in the future (EBioMedicine. 2017 Mar;17:172-81). In the study, researchers at Duke University and elsewhere identified a group of proteins in mucus that can confirm – with 86% accuracy – that the patient is infected with a cold or flu virus. They anticipate that this discovery could be adapted into a rapid test that could be performed in the doctor’s office.
However, I am sure that most of you would do a careful exam and spend a few minutes on a slightly more detailed discussion of what worrisome symptoms the parents should be watching for. But let’s be honest. Isn’t it likely that knowing that the patient has a rhinovirus infection might derail your diagnostic process short of a full consideration? Isn’t it tempting to say to yourself, “He only has a viral URI, and I even know the name of the virus. My job is done.”
Although the odds are that the virus is causing all your patient’s symptoms, there is always the chance that he or she is harboring a bacterial coinfection. Or, that what appears to be “only” a virus is actually an early step in the deadly spiral of the first episode of diabetic ketoacidosis.
This quandary is another example of the paradox in which more information can make your job as a diagnostician more difficult. Does your patient’s positive rapid strep test mean that strep is the primary cause of your patient’s fever and sore throat? Couldn’t he or she just be a carrier? Should a positive test that confirms your clinical impression put an end to your evaluation of the patient?
You could answer that you don’t have the time to go looking for zebra stripes hidden on the underbelly of every equine that gallops into your exam room. Of course you don’t. But, you are obligated to keep your mind open to the possibility that a lab test promising to make your job easy may not be telling you the whole story.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
Gene therapy for spinal muscular atrophy shows promise in early study
BOSTON – Promising results were evident in an ongoing phase I study of a gene therapy for spinal muscular atrophy type 1 (SMA1), with children in the trial walking, talking, and moving.
After a single intravenous infusion of the therapy, AVXS-101, children in the industry-funded study achieved unexpected progress in terms of physical achievement ad survival, researchers reported at the annual meeting of the American Academy of Neurology.
Video clips showed children in the trial rolling, sitting unassisted, and showing normal levels of hand and fine motor control. No other children with SMA1 have been reported to reach any major motor milestone.
In one clip, an 18-month-old boy toddles down a hallway and carries an electronic toy to an elevator where he reaches up to press the button. “He’s basically completely back to normal. You see and examine him; it just about takes your breath away,” said the study’s lead investigator, Jerry R. Mendell, MD, a neurologist at Nationwide Children’s Hospital, Columbus, Ohio.
All 15 patients in the study were alive as of the AAN presentation, with six older than aged 2 years. Previous studies have reported various life expectancies for SMA1 patients: A 2010 Korean study of 14 SMA1 patients reported that the average lifespan was 22.8 ± 2.0 months (Korean J Pediatr. 2010 Nov;53[11]:965-70), while a 2007 Hong Kong study (n = 22) found that only 30% survived to aged 4 years and all survivors were venilator-dependent (Pediatrics. 2004 Nov;114[5]:e548-53).
The open label phase I dose-escalating study recruited 15 patients (nine under aged 9 months; six 6 under aged 6 months) with SMA1 as defined by genetic criteria and onset between birth and 6 months. All received a one-time intravenous infusion of AVXS-101 after a 1-mg/1-kg dose of prednisolone the previous day. AVXS-101 is designed to boost levels of the SMN protein via delivery of a functional human SMN gene into motor neuron cells.
The first cohort of three patients received one dose. All survived to greater than aged 30 months, although one did require respiratory assistance at about 30 months, said Dr. Mendell, professor of pediatrics, neurology, pathology, and physiology and cell Biology at Ohio State University, Columbus.
Researchers moved to a larger dose, “the highest amount of virus that’s ever been given in any clinical trial,” Dr. Mendell said. The first patient has passed 30 months of age, and 9 patients have reached at least 20 months, he noted.
In this second cohort, all patients “are able to bring hand to mouth, which is obviously important for feeding. Eleven of the 12 have good head control, and 9 of the patients can roll over. And 11 can sit without assistance,” he said.
In addition, eight can sit more than 30 seconds, and two can crawl, stand, and walk independently. Eight of 12 patients are speaking, and 11 of 12 are feeding orally.
To date, five treatment-related adverse events in four patients have been reported – all asymptomatic increases in liver function enzymes, which resolved.
The study is funded by AveXis, the company developing this gene therapy. Dr. Mendell reported compensation for consulting and research support from AveXis and Sarepta Therapeutics.
BOSTON – Promising results were evident in an ongoing phase I study of a gene therapy for spinal muscular atrophy type 1 (SMA1), with children in the trial walking, talking, and moving.
After a single intravenous infusion of the therapy, AVXS-101, children in the industry-funded study achieved unexpected progress in terms of physical achievement ad survival, researchers reported at the annual meeting of the American Academy of Neurology.
Video clips showed children in the trial rolling, sitting unassisted, and showing normal levels of hand and fine motor control. No other children with SMA1 have been reported to reach any major motor milestone.
In one clip, an 18-month-old boy toddles down a hallway and carries an electronic toy to an elevator where he reaches up to press the button. “He’s basically completely back to normal. You see and examine him; it just about takes your breath away,” said the study’s lead investigator, Jerry R. Mendell, MD, a neurologist at Nationwide Children’s Hospital, Columbus, Ohio.
All 15 patients in the study were alive as of the AAN presentation, with six older than aged 2 years. Previous studies have reported various life expectancies for SMA1 patients: A 2010 Korean study of 14 SMA1 patients reported that the average lifespan was 22.8 ± 2.0 months (Korean J Pediatr. 2010 Nov;53[11]:965-70), while a 2007 Hong Kong study (n = 22) found that only 30% survived to aged 4 years and all survivors were venilator-dependent (Pediatrics. 2004 Nov;114[5]:e548-53).
The open label phase I dose-escalating study recruited 15 patients (nine under aged 9 months; six 6 under aged 6 months) with SMA1 as defined by genetic criteria and onset between birth and 6 months. All received a one-time intravenous infusion of AVXS-101 after a 1-mg/1-kg dose of prednisolone the previous day. AVXS-101 is designed to boost levels of the SMN protein via delivery of a functional human SMN gene into motor neuron cells.
The first cohort of three patients received one dose. All survived to greater than aged 30 months, although one did require respiratory assistance at about 30 months, said Dr. Mendell, professor of pediatrics, neurology, pathology, and physiology and cell Biology at Ohio State University, Columbus.
Researchers moved to a larger dose, “the highest amount of virus that’s ever been given in any clinical trial,” Dr. Mendell said. The first patient has passed 30 months of age, and 9 patients have reached at least 20 months, he noted.
In this second cohort, all patients “are able to bring hand to mouth, which is obviously important for feeding. Eleven of the 12 have good head control, and 9 of the patients can roll over. And 11 can sit without assistance,” he said.
In addition, eight can sit more than 30 seconds, and two can crawl, stand, and walk independently. Eight of 12 patients are speaking, and 11 of 12 are feeding orally.
To date, five treatment-related adverse events in four patients have been reported – all asymptomatic increases in liver function enzymes, which resolved.
The study is funded by AveXis, the company developing this gene therapy. Dr. Mendell reported compensation for consulting and research support from AveXis and Sarepta Therapeutics.
BOSTON – Promising results were evident in an ongoing phase I study of a gene therapy for spinal muscular atrophy type 1 (SMA1), with children in the trial walking, talking, and moving.
After a single intravenous infusion of the therapy, AVXS-101, children in the industry-funded study achieved unexpected progress in terms of physical achievement ad survival, researchers reported at the annual meeting of the American Academy of Neurology.
Video clips showed children in the trial rolling, sitting unassisted, and showing normal levels of hand and fine motor control. No other children with SMA1 have been reported to reach any major motor milestone.
In one clip, an 18-month-old boy toddles down a hallway and carries an electronic toy to an elevator where he reaches up to press the button. “He’s basically completely back to normal. You see and examine him; it just about takes your breath away,” said the study’s lead investigator, Jerry R. Mendell, MD, a neurologist at Nationwide Children’s Hospital, Columbus, Ohio.
All 15 patients in the study were alive as of the AAN presentation, with six older than aged 2 years. Previous studies have reported various life expectancies for SMA1 patients: A 2010 Korean study of 14 SMA1 patients reported that the average lifespan was 22.8 ± 2.0 months (Korean J Pediatr. 2010 Nov;53[11]:965-70), while a 2007 Hong Kong study (n = 22) found that only 30% survived to aged 4 years and all survivors were venilator-dependent (Pediatrics. 2004 Nov;114[5]:e548-53).
The open label phase I dose-escalating study recruited 15 patients (nine under aged 9 months; six 6 under aged 6 months) with SMA1 as defined by genetic criteria and onset between birth and 6 months. All received a one-time intravenous infusion of AVXS-101 after a 1-mg/1-kg dose of prednisolone the previous day. AVXS-101 is designed to boost levels of the SMN protein via delivery of a functional human SMN gene into motor neuron cells.
The first cohort of three patients received one dose. All survived to greater than aged 30 months, although one did require respiratory assistance at about 30 months, said Dr. Mendell, professor of pediatrics, neurology, pathology, and physiology and cell Biology at Ohio State University, Columbus.
Researchers moved to a larger dose, “the highest amount of virus that’s ever been given in any clinical trial,” Dr. Mendell said. The first patient has passed 30 months of age, and 9 patients have reached at least 20 months, he noted.
In this second cohort, all patients “are able to bring hand to mouth, which is obviously important for feeding. Eleven of the 12 have good head control, and 9 of the patients can roll over. And 11 can sit without assistance,” he said.
In addition, eight can sit more than 30 seconds, and two can crawl, stand, and walk independently. Eight of 12 patients are speaking, and 11 of 12 are feeding orally.
To date, five treatment-related adverse events in four patients have been reported – all asymptomatic increases in liver function enzymes, which resolved.
The study is funded by AveXis, the company developing this gene therapy. Dr. Mendell reported compensation for consulting and research support from AveXis and Sarepta Therapeutics.
AT AAN 2017